Multiple-Digit Pigmented Bowen's Disease Induced by Human Papillomavirus in an Immunocompetent Child

Introduction

Bowen's disease is a squamous cell carcinoma in situ, the most common malignancy of the nail unit. Presenting more frequently in the fingernails, common risk factors include ionizing radiation, oral exposure to arsenic or pesticides, dyskeratosis congenita, and quite commonly diverse subtypes of HPV. We report the first case of multiple periungual pigmented Bowen's disease in a pediatric patient.

Case Presentation

A healthy 13-year-old boy presented with a 9-month history of a pigmented erythematous patch on the proximal nail fold of his 3rd right finger without associated symptoms. A punch biopsy was taken, and the diagnosis of Bowen's disease was made. The patient received photodynamic therapy and three cycles of imiquimod without response, and two new lesions appeared on the first and second right fingers. Surgical removal was performed on all lesions. A polymerase chain reaction detected an HPV type 16.

Discussion/Conclusion

Multiple periungual Bowen's disease is rare, with the most frequent risk factors being HPV infection and chronic immunosuppression. Less than 10% of the cases present as longitudinal melanonychia. To date, there are no previous reports of multiple pigmented periungual Bowen's disease. HPV-induced Bowen's disease is usually present in adults aged between 22 and 89 years as persistent verrucae. In this case, koilocytosis and the fact that all lesions appeared on the right hand are suggestive of HPV infection.

Nail Squamous Cell Papilloma: A Rare Case Report

Introduction

Squamous cell papilloma is a benign tumor whose pathogenesis is generally related to the human papillomavirus. Despite affecting several organs, we did not find cases reported in the nails.

Case Presentation

A 67-year-old female presented with a painful lesion in the nail of the right hallux that started in 2021, with an erythematous appearance evolving to black and expansive growth. Due to the evolution and symptoms, she opted for excision, with a histopathological report of squamous cell papilloma. Complementary treatment with imiquimod was performed, with good healing and pain control.

Discussion

Due to the lack of previous reports, treatment was based on therapeutic options for papillomas located in other regions. Excision was performed, followed by application of imiquimod with good response. The prognosis is favorable; however, further studies are needed to elucidate the diagnosis and management of nail squamous cell papilloma.

Total Chemical Matricectomy With 88% Phenol: A Prospective Case Series of 37 Patients

BACKGROUND

Definitive nail dystrophies, congenital, traumatic, or acquired, affecting mainly elderly patients, may not be sufficiently managed with a periodic conservative treatment. A definitive surgical treatment may be considered an alternative method, especially in symptomatic patients.

OBJECTIVE

To evaluate the effectiveness of total matricectomy with 88% phenol solution to treat some nail dystrophies, not otherwise satisfactorily managed.

METHODS

A series of 48 surgeries were performed on 37 patients. Pain evaluation, interference with shoes and gait, recurrences, and patients' satisfaction with procedure were evaluated.

RESULTS

All patients mentioned some pain or impairment in wearing shoes before surgery. Cosmetic results were remarkable, and most of the patients (95.11%) had a dramatic improvement of their discomfort after the procedure. No severe complications occurred during the 12-month follow-up.

LIMITATIONS

Single-center study and the limited number of patients.

CONCLUSION

Total matricectomy with 88% phenol solution is an effective surgical method with low rates of postoperative morbidity and high success rates for treating symptomatic nail dystrophies. The satisfaction with the cosmetic results is high, and this is a safe procedure for patients with associated comorbidities.

Onychoscopic characteristics of Trichophyton rubrum and Trichophyton interdigitalis fungal infections: A multicentric study

BACKGROUND

Trichophyton rubrum and Trichophyton mentagrophytes variant interdigitalis are the most frequent etiologic agents of onychomycosis. Diagnosis of certainty requires mycological examination, which often results unfeasible.

OBJECTIVES

The aim of our study is to describe pathogen specific dermoscopic features, allowing a differential diagnosis without the need for cultural examination, in order to prescribe the most appropriate treatment anyway.

PATIENTS AND METHODS

We conducted an observational retrospective study on 54 patients with a culture proven diagnosis of distal subungual onychomycosis of the toenail, caused by Trichophyton rubrum or Trichophyton mentagrophytes variant interdigitalis. Using a videodermatoscope we collected data on nail colour (white, yellow, orange, brown, dark) and on dermoscopic patterns (aurora, spikes, jagged, ruin, linear edge, dots, striae).

RESULTS

Fifty-four patients, with a total of 72 nails, were eligible for this study. Analysing the association between discoloration of the nail plate and type of infection (T. rubrum or T. interdigitalis), no correlation turned out to be statistically significant. Instead, significant associations between spikes and T. rubrum infection and striae and infection from T. interdigitalis were identified. Finally, a 100% specificity was identified for white colour and ruin pattern for T. rubrum infection, and brown colour, jagged border and aurora pattern for T. interdigitalis.

CONCLUSIONS

Trying to find relationships between specific pathogens and dermoscopic patterns, we found out an association between spikes and striae and T. rubrum and T. interdigitalis respectively. Further larger studies are however necessary to evaluate our preliminary findings.

Intralesional steroid injections for inflammatory nail dystrophies in the pediatric population

Intralesional injections of triamcinolone acetonide are widely used to successfully treat several inflammatory nail conditions. This procedure is well described in adults, but less frequently reported in children and teenagers, being largely considered too invasive and fear-provoking for pediatric patients. Our report shows how this procedure is feasible and successful in children, even without a digital block. The step-by-step technique and tips to reduce pain should encourage clinicians to offer it as an alternative option to children with inflammatory nail disorders.

Diagnosis and surgical treatment of benign nail unit tumors

Little is known about benign non-melanocytic nail tumors, probably due to their low pathogenicity. They are commonly misdiagnosed as inflammatory or infective diseases. They have various features, depending on the type of tumor and its location in the nail apparatus. The typical sign of a tumor is the presence of a mass and/or secondary nail changes from damaged nail structures. In particular, if a single digit is affected by a dystrophic sign or a symptom is reported without any explanation, the presence of a tumor should always be ruled out. Dermatoscopy helps to enhance visualization of the condition and in many cases supports the diagnosis. It may also assist in identifying the right place to biopsy, but it never replaces surgery. Most common non-melanocytic nail tumors are analyzed in this paper, including glomus tumor, exostosis, myxoid pseudocyst, acquired fibrokeratoma, onychopapilloma, onychomatricoma, superficial acral fibromyxoma and subungual keratoacanthoma. The aim of our study is to review the main clinical and dermatoscopic characteristics of the most common benign non-melanocytic nail tumors, to correlate them with the histopathology and to advise practitioners of the best surgical management.

Onychomycosis: Recommendations for Diagnosis, Assessment of Treatment Efficacy, and Specialist Referral. The CONSONANCE Consensus Project

Introduction

Onychomycosis is the most common nail disorder in adults, with high recurrence and relapse rates. Its diagnosis may be difficult by non-experts because the clinical signs may overlap with other dermatoses. The treatment may be challenging, as it should be patient-tailored.

Methods

An online survey was conducted among European Nail Society (ENS) members to provide recommendations on the diagnosis and assessment of distal lateral subungual onychomycosis (DLSO) in non-specialized clinical environments, as well as recommendations for patient referral.

Results

DLSO diagnosis is predominantly based on clinical aspects, and microscopy and fungal culture are commonly employed to establish the diagnosis. Assessment of clinical features is the main method for DLSO follow-up, and the main criterion to define cure is a combination of mycologic cure and clinical cure. The most commonly selected treatments for onychomycosis include oral antifungals, topical antifungals, and nail debridement. According to the nail experts, predisposing factors of DLSO to be evaluated include concurrent tinea pedis diagnosis, immunocompromised status, and diabetes. The minimum clinical aspects to be evaluated for DLSO diagnosis should include subungual hyperkeratosis, white-yellow-orange subungual scales, and absence of salmon-pink coloration. Recommendations for clinical signs that should be evaluated to confirm treatment effectiveness include normal appearance and color of the nail, reduction or absence of scales under the nail, and absence of onycholysis. Recommendations for specialist referral include lack of treatment effectiveness, need of additional therapies, concurrent presence of other diseases or comorbidities, severe DLSO, and presence of a dermatophytoma or involvement of the nail matrix.

Conclusions

According to the surveyed nail experts, after evaluating clinical signs and predisposing factors for DLSO, the diagnosis should include subungual hyperkeratosis, nail color (yellow-orange), and onycholysis and thickening. In cases of severe DLSO, when there is treatment failure, concomitant diseases/comorbidities, presence of a dermatophytoma or involvement of the nail matrix, or involvement of several/all nails, referral should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00698-x.

Fungal Viability of Nail Dust from Onychomycosis Abrasion: A Pilot Study

Introduction

Onychomycosis is a frequent complaint in dermatological practice and corresponds to the most common nail disease. The treatment of onychomycosis remains a challenge, as several factors end up compromising and making treatment difficult. Nail abrasion is considered a useful method in many cases. However, there is controversy about this approach, as there is an aerosol formation that could contaminate the environment and cause fungal changes or hypersensitivity reactions by the disseminated dust. We conducted a pilot study to investigate the fungal viability of nail particles from nails with onychomycosis after abrasion procedure.

Methods

In this study, nail dust from the gloves and mask, used in the procedure, was collected from 9 patients with clinical and dermoscopic diagnoses of onychomycosis.

Results

Hyaline septate hyphae were found in 12 materials (gloves and/or masks) from 7 patients. However, these hyphae were morphologically deformed or mutilated in all exams. In Mycosel® agar, there was no growth of any fungus.

Discussion/Conclusion

The absence of dermatophyte isolation in all fungal cultures may demonstrate that the deformed fungal structures shown are not viable and would not present risks of contamination after nail abrasion.

Prevalence of Onychomycosis among Patients with Transverse Overcurvature of the Nail: Results of a Cross-Sectional Study

Introduction

Transverse overcurvature of the nail (TON) represents one of the main reasons for dermatological consultations due to nail conditions. Association between TON and subungual hyperkeratosis is common and simulates onychomycosis, constituting a difficult differential diagnosis by clinical features. Many cases are treated in daily practice with antifungal therapy even without mycological confirmation. The aim of this study was to determine the prevalence of onychomycosis among patients with TON associated with subungual hyperkeratosis.

Methods

All subjects with clinical diagnosis of TON and subungual hyperkeratosis were subjected to a thorough clinical history, detailed clinical examination, digital photography, and collection of nail clipping and subungual debris for histopathological and microbiological examination (direct microscopy).

Results

Sixty-five samples were collected from 62 female (95.4%) and 3 male (4.6%) participants. Age range was between 34 and 83 years (mean age, 61.2 years). Twenty-eight samples were positive for onychomycosis, giving a 43.07% prevalence rate of onychomycosis among TON associated with hyperkeratosis.

Discussion/Conclusion

According to our data, the prevalence of onychomycosis in patients with TON associated with subungual hyperkeratosis was 43.07%, confirming the need to rule out fungal infection in TON associated with subungual hyperkeratosis prior to considering any unnecessary antifungal treatment.

Onychomatricoma of the Nail Bed

Onychomatricoma is a rare and specific benign tumor of the nail complex, with uncertain etiology. The avulsion of the nail plate reveals cavitations and orifices in its proximal extremity. These are associated with villous tumor formations generating digitiform projections at the nail matrix - typical intraoperative findings. We report a rare case of onychomatricoma in which the nail bed was predominantly affected and show evidence of its clinical, intraoperative, and histopathological presentation. The various descriptions of the disease report that its origin is restricted to the nail matrix, leading to secondary changes in the nail plate.

Unusual size, topography, and surgical resolution of an acquired fibrokeratoma

Acquired fibrokeratoma is a rare benign skin tumor that usually manifests as a slow-growing solitary nodular lesion of the digits. We report a case of plantar acquired fibrokeratoma evidencing its atypical size and topography, in addition to the treatment with simple surgical excision followed by healing by second intention. Nondigital fibrokeratomas may occur in 18% of cases and rarely affect the palmoplantar region. These lesions are usually asymptomatic and show ≥ 3cm in size at the time of diagnosis due to delayed diagnosis. Complete surgical excision is the treatment of choice, which is usually curative. In general, primary closure is chosen; however healing by second intention becomes an option in regions of difficult approach.

Congenital Curved Nail of the Fourth Toe Associated with Oral Disorders

Congenital curved nail of the fourth toe represents an unusual deformity in which the nail of the fourth toe curves in a plantar direction. It is unknown why only this toe is affected; however, the initial descriptions suggest that this is a mesodermal defect. We describe a case of congenital curved nail of the fourth toe associated with bifid uvula. There are only 2 reports mentioning the association of this nail abnormality with cleft palate and/or lip. In our patient, there was an association with bifid uvula that is considered a minor form of palatine fissure. There seems to be an association of congenital curved nail of the fourth toe with cleft palate to different degrees; however, the pathogenesis of the deformity remains unknown.

Pigmented onychomatricoma: Four cases

Onychomatricoma (OM) presenting as a longitudinal melanonychia is a very uncommon clinical presentation with very few cases in the literature. Our aim in this article is to report four cases of pigmented OM, and describe their clinical and dermoscopic findings and the importance of the differential diagnoses, especially with melanoma.

Subungual Melanoma In Situ Treated With Imiquimod 5% Cream After Conservative Surgery Recurrence

<p>Subungual melanoma is a rare variant of acral lentiginous melanoma that often has a poor prognosis compared with other types of melanoma. The aim of the present study is to report a case of a patient with recurrence of subungual melanoma treated with imiquimod 5%, which presented a total regression of the lesion and no recurrence for 4 years.</p> <p><em>J Drugs Dermatol. 2017;16(3):268-270.</em></p>.

Periungual Lesion due to Secondary Syphilis

Several countries experience a new epidemic of syphilis, mainly due to the changes in risk behaviors. Dermatologists play an important role in the diagnosis, since cutaneous manifestations are frequent during disease progression. We report a rare case of secondary syphilis with periungual involvement. Syphilis, especially in the secondary form, may present with different clinical features, affecting different organs, and mimicking many diseases. Although nail apparatus lesions are more common in the primary form of the disease, they may also be present in the secondary and tertiary forms. Therefore, a comprehensive knowledge of the diverse forms of syphilis presentation is important for an early diagnosis and timely treatment.

Onychomatricoma: a tumor unknown to dermatologists

A sixty-one year old white female was referred to the Dermatology Department to treat an ingrown nail in the inner corner of the left hallux. Examination of the entire nail unit showed the presence of xanthonychia in the outer corner besides thickening and increase in the transverse curvature of the nail plate. Dermoscopy and nuclear magnetic resonance of the free edge of the nail plate detected characteristic signs of onychomatricoma, a diagnosis that was later confirmed by anatomopathological exam.

Syndrome in Question

The Iso-Kikuchi Syndrome is a rare condition characterized by nail dysplasia involving the index fingers, including micronychia, polyonychia, anonychia, irregular lunula, malalignment and hemionychogryphosis. On the antero-posterior image, radiologic examination reveals a narrowing of the distal phalanx. The lateral image shows a Y-shaped bifurcation of the distal phalanx. We report a case of a patient with typical clinical and radiologic signs of Iso-Kikuchi Syndrome.

Dermoscopy examination of petechial lesions in a patient with Dermatitis Herpetiformis

An uncommon skin manifestation of Dermatitis Herpetiformis is palmar and plantar purpura. Dermoscopic examination is useful for any skin condition since it allows recognition of structures that are not discernible to the naked eye. A 22 year-old Caucasian man was admitted with excoriated lesions and pruritus. Petechial lesions could be seen on volar aspect of the digits on the hands and feet. Dermoscopy examination revealed erythematous and violaceous dots and erythematous and brown dots.

Involucrin in the differential diagnosis between linear psoriasis and inflammatory linear verrucous epidermal nevus: a report of one case

Inflammatory linear verrucous epidermal nevus is a variant of verrucous epidermal nevus, characterized by recurrent inflammatory phenomena. Despite well-established clinical manifestations, the differential diagnosis between inflammatory linear verrucous epidermal nevus and linear psoriasis remains difficult. Clinical history, physical examination and histopathology analysis may not be sufficient to confirm the diagnosis. We report the case of a 4-year-old girl in which the involucrin immunostaining was helpful in the diagnosis of inflammatory linear verrucous epidermal nevus. Our findings confirm that involucrin immunohistochemistry is a useful tool in such cases.

Synchronous subungual glomus tumors in the same finger

The glomus tumor is an uncommon benign neoplasm of glomus cells. In the majority of the cases it is presented as a solitary painful papule in the subungual region. We report a rare case of a patient with two individual synchronous glomus tumors under the nail bed of the same finger.

Caso para diagnóstico

Pacientes com ferimentos penetrantes plantares com presença de corpo estranho são atendidos em serviços de emergência, clínicas ortopédicas e dermatológicas. As características clínicas dessas lesões são pouco citadas em periódicos e livros textos dermatológicos. Relatamos um caso de corpo estranho plantar em que a história clínica e o exame dermatológico foram decisivos para o diagnóstico.